Assessment of Inappropriate Sexual Behavior in Dementia

Interviewing the patient as well as informal and formal caregivers, as appropriate, is essential to evaluate and contextualize ISB in the clinical picture as a whole. This may have to be done by considering all information sources and by sensibly interviewing all informants separately, at least during part of the consultation. Is it due to dementia itself? Is it due to comorbidities unrelated with dementia? Is it due to cognitive symptoms not only related to dementia, but, e.g., to superimposed delirium, not yet recognized? A complete medical history and physical examination should be conducted in order to provide answers to these questions or hypotheses to test. A detailed sexual history should be taken. Past history of maladaptive personality (or even personality disorder) or behavioral disturbances (e.g., impulsivity, dis- inhibition) should be sought. This general approach, together with careful questioning on the circumstances of the specific behavior under analysis, may be crucial to consider the identified complaint or problem into a personal and family context. Clinical explorations should include a thorough description of how the symptoms appeared (a sudden onset may suggest a general medical etiology), in what circumstances and in relation to which potential precipitants (for instance, some patients may only have symptoms during daily hygiene due to a misinterpretation of the context), if they tend to be associated with certain caregivers (for instance, symptoms may be due to misidentification, by erroneously taking a particular caregiver for another person with a particular meaning in the patient’s life; alternatively, ISB may signal inconspicuous forms of abuse), and finally if behaviors tend to occur during a specific time of the day, for how long do they subsist and how often do they appear. Association with some medical treatments should be explored (for instance, trazodone may cause priapism, albeit rarely; benzodiazepines can be associated with ISB by means of paradoxical disinhibition, while disinhibition may also be due to SSRI) [14]. The type of sexual behaviors must be carefully explored. As already mentioned, many patients can be misinterpreted because they fail to find their own bedroom, or they may remain undressed because they are no longer able to dress correctly. Frequently disrobing, whereas interpreted as overtly sexual disinhibition, may actually be a manifestation of discomfort (e.g., on account of pruritus, excessive heat, or even pain) or appear in the context of unspecific agitated behavior, with undressing as a purposeless activity. In these cases, it is frequent that patients cannot explain their own action or even understand they are being socially incorrect. The patient might be easily interrupted but can continue soon after that short interruption in a form of purposeless hyperactivity.

If a medical comorbidity etiology is sought, laboratory testing should be conducted, according to the clinical clues or symptoms. In most cases a complete urogenital evaluation must be done, as local infections or inflammations can be the cause of discomfort or pain.

There is a scarcity of validated instruments to assess challenging sexual behaviors among patients with neurological diseases such as dementia. Scales commonly used to approaching behavioral changes in dementia lack specificity concerning ISB evaluation: ISB is collected within other behavioral changes, as, for instance, within the item “disinhibition” (irrespective of the type) in the Neuropsychiatric Inventory [15 ] or within the item “inappropriate activity” in the BEHAVE-AD inventory, or even within agitation items [16] . In the Cohen-Mansfield agitation inventory, two items approach sexual behaviors, although no severity rating is given

[17]. Some specific measures may be useful to improve the comparability of results in different studies and can even have potential clinical utility [18], but its use is not widespread.

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